About
Application
E&O Application
Crime Application
Cyber Application
Coverage
E&O
Crime
Cyber/Data Breach
Bonds
Contact
Print Forms
Cyber Application
General Information
Applicant Name
*
Applicant Contact Name
*
Applicant Contact Title
*
Physical Address
*
Physical Address Line 2
City
*
State
*
-- Select a State --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
*
Mailing Address
Mailing Address Line 2
If different from physical address
City
State
-- Select a State --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Email Address
*
Website
Phone Number
*
Include extension, if applicable
Fax Number
Officers & Owners
×
Name
*
Age
Title
Ownership %
*
%
Active in Daily Business?
*
Yes
No
Ownership
0%
+ Add Another Officer/Owner
Revenues
12-month Gross Revenues
*
$
Your retained commission after paying underwriters
plus
revenue/fees from closing, escrow, or title searches.
Cyber Threat Protection
Any "No" responses will require an explanation.
Is data backed up on a regular basis?
*
Yes
No
Explain your "No" Response
*
Are anti-virus and firewall systems in place and updated on a regular basis (at least quarterly)?
*
Yes
No
Explain your "No" Response
*
Are mandatory individual, unique, non-trivial IDs and passwords utilized for all devices?
*
Yes
No
Explain your "No" Response
*
Are all laptops, computers, and mobile devices storing Personally Identifiable Information (PII) encrypted?
*
Yes
No
Explain your "No" Response
*
Can you confirm that the applicant does not accept any credit card transactions which are not processed by a payment processor?
*
Yes
No
Explain your "No" Response
*
Are the number of unique
PII
/ Personal Health Information records less than 500,000 (1,000,000 if revenues are in excess of $5,000,000)?
*
Yes
No
Explain your "No" Response
*
Can you confirm that the applicant has not sustained a system intrusion, tampering, virus, or malicious code attack, loss of data, hacking incident, data theft, or similar incident within the past 5 years?
*
Yes
No
Explain your "No" Response
*
Can you confirm that no person has alleged that their confidential information has been compromised?
*
Yes
No
Explain your "No" Response
*
Can you confirm that the applicant has not sustained any unscheduled network outage or interruption in the past 24 months, except where the outage has been caused by natural events (storms, tornadoes, etc.)?
*
Yes
No
Explain your "No" Response
*
Can you confirm that the applicant has not experienced any claims or losses, or are aware of any circumstances that could give rise to a claim or loss that may have been covered by this policy?
*
Yes
No
Explain your "No" Response
*
Submit Form
